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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200973
Report Date: 04/23/2024
Date Signed: 04/23/2024 04:51:31 PM


Document Has Been Signed on 04/23/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BETHANY HOME SENIOR LIVING, LLCFACILITY NUMBER:
019200973
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:3322 EAST AVE.TELEPHONE:
(925) 443-6822
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:58CENSUS: 32DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rachell Paniagua, ManagerTIME COMPLETED:
05:00 PM
NARRATIVE
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On 4/23/2024 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with receptionist, Eszter Ujvari and explained the purpose of the visit. Manager, Rachell Paniagua arrived an hour later.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 5/10/2023. Evacuation chairs were observed in both stairwell on the third floor. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food once a week. Freezer’s temperature was registered at 0 degree F while the refrigerator’s temperature was recorded at 37 degrees F. Hot water temperature was measured at 112.6 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid mats were observed. LPA reviewed 5 resident records and 5 staff records starting at 10:15AM. LPA conducted interviews with 3 residents and 3 staff during inspection. LPA also reviewed a sample of resident's medications.

At 2:00PM, LPA observed S2 and S3 does not have completed health screening on file. S2 does not have TB test on file.

At 4:00PM, LPA observed R2's Calcium Carbonate was ordered 500mg one tab by mouth 2 times a day. However, LPA observed facility has a bottle of Calcium Carbonate 600mg that was given to R2. Also, R2 ran out of Cholecalciferol (Vitamin D3).

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 04/23/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHANY HOME SENIOR LIVING, LLC
FACILITY NUMBER: 019200973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test for staff which poses a potential health and safety risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Facility has agreed to obtain health screening for S2 and S3 and TB test results for S2. Facility will submit copies of documents to CCLD by POC date.

Civil penalty of $250 is being assessed for a repeat violation.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/23/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BETHANY HOME SENIOR LIVING, LLC
FACILITY NUMBER: 019200973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's order for R2's medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Facility purchased Calcium Carbonate 500mg and Cholecalciferol (Vitamin D3) during inspection.

Deficiency cleared. Civil penalty of $250 is being assessed for a repeat violation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3